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Surgery Oct 2021Ampullary carcinoma patients require radical resection for optimal survival; however, the outcomes are often unsatisfactory. The utility of adjuvant therapy among such... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ampullary carcinoma patients require radical resection for optimal survival; however, the outcomes are often unsatisfactory. The utility of adjuvant therapy among such patients is unclear, probably owing to its potential side effects. Therefore, this study investigated the benefits and safety of adjuvant therapy in resected ampullary carcinoma.
METHODS
Cochrane, Embase, Medline, and PubMed databases were systematically searched for eligible studies, and those comparing adjuvant therapy and surgical treatment alone were included. Hazard ratios for survival outcomes and the number of adverse events for safety endpoints were extracted and subjected to pooled analyses through a random-effects model.
RESULTS
In total, 27 studies involving 3,538 patients were included. Adjuvant therapy was significantly associated with decreased mortality risk (hazard ratio, 0.58; 95% confidence interval 0.40-0.84), especially for chemoradiotherapy (hazard ratio, 0.42; 95% confidence interval 0.28-0.62). Furthermore, adjuvant therapy was significantly associated with increased overall survival among high-risk patients (hazard ratio, 0.63; 95% confidence interval 0.48-0.82) or those with the pancreaticobiliary subtype (hazard ratio, 0.53; 95% confidence interval 0.32-0.85). By contrast, adjuvant therapy was not associated with improved overall survival among low-risk patients (hazard ratio, 0.93; 95% confidence interval 0.52-1.68) or those with the intestinal subtype (hazard ratio, 1.06; 95% confidence interval 0.57-1.95). Regarding the safety of adjuvant therapy, no intervention-related mortality occurred, and severe adverse events were within the acceptable range (risk difference, 0.04; 95% confidence interval 0.01-0.08).
CONCLUSION
The present results suggest that adjuvant therapy is safe and extends survival in high-risk patients or those with the pancreaticobiliary subtype of ampullary carcinoma.
Topics: Ampulla of Vater; Antineoplastic Agents; Carcinoma, Pancreatic Ductal; Chemotherapy, Adjuvant; Humans; Pancreatectomy; Pancreatic Neoplasms; Postoperative Care; Treatment Outcome
PubMed: 33902926
DOI: 10.1016/j.surg.2021.03.046 -
Langenbeck's Archives of Surgery Mar 2018Predicting the biologic behavior of intraductal papillary mucinous neoplasm (IPMN) remains challenging. Current guidelines utilize patient symptoms and imaging... (Review)
Review
Can we better predict the biologic behavior of incidental IPMN? A comprehensive analysis of molecular diagnostics and biomarkers in intraductal papillary mucinous neoplasms of the pancreas.
PURPOSE
Predicting the biologic behavior of intraductal papillary mucinous neoplasm (IPMN) remains challenging. Current guidelines utilize patient symptoms and imaging characteristics to determine appropriate surgical candidates. However, the majority of resected cysts remain low-risk lesions, many of which may be feasible to have under surveillance. We herein characterize the most promising and up-to-date molecular diagnostics in order to identify optimal components of a molecular signature to distinguish levels of IPMN dysplasia.
METHODS
A comprehensive systematic review of pertinent literature, including our own experience, was conducted based on the PRISMA guidelines.
RESULTS
Molecular diagnostics in IPMN patient tissue, duodenal secretions, cyst fluid, saliva, and serum were evaluated and organized into the following categories: oncogenes, tumor suppressor genes, glycoproteins, markers of the immune response, proteomics, DNA/RNA mutations, and next-generation sequencing/microRNA. Specific targets in each of these categories, and in aggregate, were identified by their ability to both characterize a cyst as an IPMN and determine the level of cyst dysplasia.
CONCLUSIONS
Combining molecular signatures with clinical and imaging features in this era of next-generation sequencing and advanced computational analysis will enable enhanced sensitivity and specificity of current models to predict the biologic behavior of IPMN.
Topics: Adenocarcinoma, Mucinous; Biomarkers, Tumor; Biopsy, Needle; Carcinoma, Pancreatic Ductal; Female; Humans; Immunohistochemistry; Incidental Findings; Male; MicroRNAs; Needs Assessment; Pancreatic Neoplasms; Pathology, Molecular; Practice Guidelines as Topic; Predictive Value of Tests; Prognosis; Risk Factors
PubMed: 29218397
DOI: 10.1007/s00423-017-1644-z -
World Journal of Surgical Oncology Jan 2014Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare,... (Review)
Review
BACKGROUND
Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare, and more frequently discovered after a primary diagnosis of breast cancer. Solitary pancreatic metastases from breast cancer, without widespread disease, are actually unusual, and only 19 cases have been previously described; truly exceptional is a solitary pancreatic metastasis becoming evident together with the primary breast cancer.
CASE PRESENTATION
A 68-year-old woman reported general fatigue, lethargy, and jaundice. Abdominal ultrasound (US) and magnetic resonance imaging (MRI) showed an ampulloma of Vater's papilla; moreover, a neoplastic nodule in the left breast was diagnosed. She underwent surgery for both breast cancer and ampulloma of Vater's papilla. Pathological examination of pancreatic specimen, however, did not confirm primary carcinoma of the duodenal papilla, but showed a metastatic involvement of pancreas from lobular breast cancer. Immunohistochemistry has been essential to confirm the origin of the malignancy: hormone receptors and mammaglobin were expressed in both the primary breast tumor and the pancreatic metastasis.
CONCLUSIONS
This is one of the few reported cases in literature of an isolated and synchronous pancreatic metastasis from breast cancer, where the definitive diagnosis was obtained only after surgery. We discuss the controversies in this diagnosis and the choice of correct treatment. The surgical resection of solitary metastases can be performed in the absence of disseminated disease.
Topics: Aged; Breast Neoplasms; Carcinoma, Lobular; Combined Modality Therapy; Female; Humans; Pancreatic Neoplasms; Prognosis
PubMed: 24387226
DOI: 10.1186/1477-7819-12-2 -
Strahlentherapie Und Onkologie : Organ... Feb 2019Non-surgical treatment including stereotactic body radiation therapy (SBRT) have been used practically as alternative modalities for unresectable or recurrent... (Meta-Analysis)
Meta-Analysis
PURPOSE
Non-surgical treatment including stereotactic body radiation therapy (SBRT) have been used practically as alternative modalities for unresectable or recurrent cholangiocarcinoma (CC). We performed a systematic review and meta-analysis to examine the efficacy of SBRT for such patients.
METHODS
Embase, PubMed, MEDLINE, and Cochrane library databases were searched systematically until October 2017. Primary endpoint was 1‑year local control (LC) rate; 1‑year overall survival (OS), response rates, and grade ≥3 toxicities were assessed as secondary endpoints.
RESULTS
Eleven studies (226 patients) were included. The prescribed median SBRT dose was 45 (range 30-55) Gy in 3-5 fractions. The pooled 1‑year LC rate was 81.8% (95% confidence interval [CI] 69.4-89.9%) in the studies using an equivalent dose in 2 Gy per fraction (EQD2) ≥71.3 Gy and 74.7% (95% CI 57.1-86.7%) in the studies using an EQD2 <71.3 Gy. The median OS was 13.6 (range 10-35.5) months. The pooled 1‑year OS rate was 53.8% (95% CI 44.9-62.5%) and the pooled 1‑year LC rate was 78.6% (95% CI 69.0-85.8%). Most common toxicity was duodenal ulcer and gastric ulcer in available studies, with the acute incidence of grade ≥3 of less than 10% and the late incidence of 10-20%.
CONCLUSIONS
SBRT was a feasible treatment option with respect to achieving a high LC for unresectable or recurrent CC. Gastrointestinal toxicity is acceptable, but remains an obstacle related to dose escalation.
Topics: Bile Duct Neoplasms; Cholangiocarcinoma; Feasibility Studies; Humans; Neoplasm Recurrence, Local; Radiosurgery; Radiotherapy Dosage; Survival Rate; Treatment Outcome
PubMed: 30206644
DOI: 10.1007/s00066-018-1367-2 -
Minerva Chirurgica Jun 2019Once liver metastases in pancreatic and periampullary carcinoma are diagnosed, guidelines do not recommend resection of the primary tumor. In this stage of the disease,...
INTRODUCTION
Once liver metastases in pancreatic and periampullary carcinoma are diagnosed, guidelines do not recommend resection of the primary tumor. In this stage of the disease, therapeutic regimes with chemotherapy are the standard treatment. However, it is unclear whether combinations of extensive surgery and novel chemotherapy treatments confer a survival benefit in selected patients.
EVIDENCE ACQUISITION
We provide a systematic review about liver metastases in pancreatic and periampullary carcinoma treated by surgery utilizing EMBASE, Medline/PubMed, Cochrane and Scopus databases according to PRISMA guidelines.
EVIDENCE SYNTHESIS
In pancreatic and periampullary carcinoma, the number of lesions that can be resected includes a mean or median of 1-3; the size of the lesions should not exceed 3 cm and the most frequent surgical technique used were wedge or atypical resections. Overall morbidity and mortality after liver resection from pancreatic tumors were 0-68% and 0-9.1%, respectively, and from periampullary carcinomas were 0-82% and 0-21%, respectively. Considering both types of carcinomas, the rate of recurrence was up to 91%. Median overall survival ranged from 5.5 to 16.6 months for liver metastases from pancreas carcinoma, and from 5 to 23 months for periampullary carcinoma, with better prognosis for duodenal carcinomas.
CONCLUSIONS
Perioperative chemotherapy is the cornerstone of treatment in patients with liver metastasis from pancreatic and periampullary carcinoma. Liver resection from early liver metastases could be acceptable in selected patients with oligometastatic disease and small single lesions taking into account the individual risk of complications.
Topics: Ampulla of Vater; Carcinoma, Pancreatic Ductal; Disease-Free Survival; Duodenal Neoplasms; Humans; Liver Neoplasms; Neoplasm Recurrence, Local; Pancreatic Neoplasms
PubMed: 30600968
DOI: 10.23736/S0026-4733.18.07972-5 -
Perineural Invasion is a Strong Prognostic Moderator in Ampulla of Vater Carcinoma: A Meta-analysis.Pancreas Jan 2019Ampulla of Vater carcinoma (AVC) has a broad spectrum of different prognoses. As such, new moderators of survival are urgently needed. We aimed at clarifying the... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Ampulla of Vater carcinoma (AVC) has a broad spectrum of different prognoses. As such, new moderators of survival are urgently needed. We aimed at clarifying the prognostic role of perineural invasion in AVC.
METHODS
Using PubMed and SCOPUS databases, we conducted the first systematic review and meta-analysis on this topic.
RESULTS
Analyzing 29 articles for a total of 2379 patients, we found that the presence of perineural invasion increased the risk of all-cause mortality more than 2 times (relative risk [RR], 2.07; 95% confidence interval [CI], 1.78-2.42 [P < 0.0001]; hazard ratio [HR], 2.72; 95% CI, 1.86-3.97 [P < 0.0001]), of cancer-specific mortality more than 6 times (RR, 6.12; 95% CI, 3.25-11.54 [P < 0.0001]; HR, 6.59; 95% CI, 2.29-3.49 [P < 0.0001]), and of recurrence more than 2 times (RR, 2.63; 95% CI, 1.89-3.67 [P < 0.0001]; HR, 2.54; 95% CI, 1.24-5.21 [P = 0.01]).
CONCLUSIONS
Perineural invasion is strongly associated with a poorer prognosis in AVC, influencing both survival and risk of recurrence. It should be reported in the final pathology report and should be taken into account by future oncologic staging systems, identifying a group of AVC with a more malignant biological behavior.
Topics: Ampulla of Vater; Carcinoma, Pancreatic Ductal; Humans; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Pancreatic Neoplasms; Perineum; Prognosis; Risk Factors
PubMed: 30451797
DOI: 10.1097/MPA.0000000000001194 -
Clinical & Translational Oncology :... Aug 2020Given the lack of evidence on the best adjuvant approach, this review closely examines optimal adjuvant management for resected true ampullary cancer and its...
BACKGROUND
Given the lack of evidence on the best adjuvant approach, this review closely examines optimal adjuvant management for resected true ampullary cancer and its histological subtypes.
MATERIALS AND METHODS
A comprehensive literature search of PubMed was performed to identify studies on resected true ampullary cancers, published between January 2010 and December 2018. Data including the use of radiation, chemotherapy or chemoradiation and the outcomes were extracted.
RESULTS
A total of 116 records were identified, of which 65 screened were selected. Finally, nine studies were included. Only two of the studies reported separately the outcomes of pancreatobiliary and intestinal subtypes. Patients in the selected studies were treated with a pancreaticoduodenectomy with negative margins. Patients treated with adjuvant therapy were more likely to be pT3-4 and have positive nodes; median survival ranged from 30 to 47 months. A significant benefit for adjuvant treatment was observed in four of the studies, restricted to patients at stage IIB or higher. Likewise, patients with positive nodes may have a longer median survival with adjuvant chemoradiation compared to observation.
CONCLUSIONS
The present review suggests a benefit for adjuvant treatment for patients with locally advanced tumors. Randomized trials are needed to ascertain the topic, as well as studies reporting toxicity and quality of life of resected true ampullary cancer patients.
Topics: Adenocarcinoma; Ampulla of Vater; Carcinoma; Carcinoma, Pancreatic Ductal; Chemoradiotherapy, Adjuvant; Chemotherapy, Adjuvant; Common Bile Duct Neoplasms; Duodenal Neoplasms; Humans; Pancreaticoduodenectomy; Radiotherapy, Adjuvant; Retrospective Studies; Treatment Outcome
PubMed: 31927720
DOI: 10.1007/s12094-019-02278-6 -
ANZ Journal of Surgery Feb 2024The majority of patients with pancreatic adenocarcinoma (PDAC) have advanced disease at presentation, preventing treatment with curative intent. Management of these...
BACKGROUND
The majority of patients with pancreatic adenocarcinoma (PDAC) have advanced disease at presentation, preventing treatment with curative intent. Management of these patients is often provided by surgical teams for whom there are a lack of widely accepted strategies for care. The aim of this study was to conduct a systematic review to identify key issues in patients with advanced PDAC and integrate the evidence to form a care bundle checklist for use in surgical clinics.
METHODS
A systematic review of the literature was performed regarding best supportive care for advanced PDAC according to the PRISMA guidelines. Interventions pertaining to supportive care were included whilst preventative and curative treatments were excluded. A narrative review was planned.
RESULTS
Forty-four studies were assessed and four themes were developed: (i) Pain is an undertreated symptom, requiring escalating analgesics and sometimes invasive modalities. (ii) Health-related quality of life necessitates optimisation by involving family, carers and multi-disciplinary teams. (iii) Malnutrition and weight loss can be mitigated with early assessment, replacement therapies and resistance exercise. (iv) Biliary and duodenal obstruction can often be relieved by endoscopic/radiological interventions with surgery rarely required.
CONCLUSION
This is the first systematic review to evaluate the different types of interventions utilized during best supportive care in patients with advanced PDAC. It provides a comprehensive care bundle for surgeons that informs management of the common issues experienced by patients within a multidisciplinary environment.
PubMed: 38366699
DOI: 10.1111/ans.18906